European Journal of Case Reports in Internal Medicine <p><strong>The&nbsp;<span class="HPblu">European Journal of Case Reports in Internal Medicine</span>&nbsp;</strong>is an official journal of the European Federation of Internal Medicine (EFIM), representing 35 national societies from&nbsp;<a href="">33 European countries</a>.&nbsp;<br><br>The journal’s mission is to promote the best medical practice and innovation in the field of acute and general medicine. It also provides a forum for internal medicine doctors where they can share new approaches with the aim of improving diagnostic and clinical skills in this field.&nbsp;<strong><br><span class="HPblu">EJCRIM&nbsp;</span></strong>welcomes high-quality case reports describing unusual or complex cases that an internist may encounter in everyday practice. The cases should either demonstrate the appropriateness of a diagnostic/therapeutic approach, describe a new procedure or maneuver, or show unusual manifestations of a disease or unexpected reactions. The Journal only accepts and publishes those case reports whose learning points provide new insight, contribute to advancing medical knowledge both in terms of diagnostics and therapeutic approaches. Case reports of medical errors, therefore, are also welcome as long as they provide innovative measures on how to prevent them in the current practice (Instructive Errors).&nbsp;<strong><br></strong>The Journal may also consider brief and reasoned reports on issues relevant to the practice of Internal Medicine, as well as Abstracts submitted to the scientific meetings of acknowledged medical societies.<br><br> <strong>EJCRIM</strong> is peer-reviewed with single-blind review and freely accessible to all.</p> SMC media s.r.l. - Via Giovenale 7, Milan - Italy en-US European Journal of Case Reports in Internal Medicine 2284-2594 <h3>Copyright and Disclosures</h3> <p>Every author must sign a copyright transfer agreement and disclose any financial or professional interest in any company, product, or service mentioned in an article. This authorization includes all submitted text including illustrations, tables, and other related materials.<br> If this submission contains any <strong>material that has been previously published</strong>, this authorization <strong>must also be accompanied</strong> by all necessary Permission to Reproduce Published Material" forms completed by the current copyright owner. If this submission contains any <strong>previously unpublished material</strong> for which the person(s) signing this form <strong>does not own copyright</strong>, an additional "Authorization to Publish" form is required from each corresponding copyright owner.</p> <h3>Copyright Transfer Declaration</h3> <p>(this may be included as a word document with your manuscript submission)<br> I confirm that I am the current copyright owner of the material described above and hereby transfer and assign to the European Journal of Case Reports in Internal Medicine (EJCRIM) all copyrights in and to the material for publication throughout the world, in all forms and media, in English and in any other language(s). Such transfer includes publication in this and all future editions of the publication named above and in any other publications (including slide collections and any other nonprint media) of EJCRIM and gives EJCRIM the sole authority to grant rights for use of the material by others.<br> I waive EJCRIM from any liabilities connected to the incorrect copyright statement.<br>The copyright agreement form can be downloaded <a style="font-weight: bold;" href="/documents/EJCRIM_Copyright_auth.pdf">HERE</a> or requested to the editorial office <a style="font-weight: bold;" href=""></a></p> Seropositive Rheumatoid Arthritis with Very Unusual X-ray Findings <p>We described the case of a 23-year-old Nepalese man with seropositive rheumatoid arthritis and abnormal x-ray findings, found to be due to a very rare bone disease: Camurati Engelmann disease or progressive diaphyseal dysplasia (PDD). This is the first case reported in the Gulf area, although approximately 300 cases have been described worldwide. These patients usually present with limb pain and easy fatigability. Our patient first presented with bilateral, symmetrical inflammatory polyarthritis involving the knees, ankles and wrists but sparing the hands and feet. The diagnosis of PDD in our case was based on the classic radiological findings and a bone scan.</p> Laith Alamlih Mohamed Alkahlout Abdulrahim Siam Syed Alam Abdul-Wahab Al-Allaf ##submission.copyrightStatement## 2018-04-24 2018-04-24 5 4 10.12890/2018_000883 Primary Hepatic Diffuse Large B-cell Lymphoma Mimicking Acute Fulminant Hepatitis <p>Primary hepatic lymphoma (PHL) is a rare variant of non-Hodgkin's lymphoma. Diffuse hepatic involvement is uncommon and therefore presentation as progressive hepatitis or acute fulminant hepatic failure is rare. Acute onset of signs and symptoms can mimic a variety of infectious and inflammatory disorders, thus delaying the diagnosis. A high index of suspicion and liver biopsy early in the course of liver dysfunction may establish the diagnosis and allow rapid initiation of chemotherapy to prevent a fatal outcome. In this report, we describe a rare case of fulminant primary hepatic diffuse large B-cell lymphoma in a 55-year-old woman who died 2 weeks after admission, before the initiation of chemotherapy.</p> Toni El Murr Ricardo El Nouwar ##submission.copyrightStatement## 2018-04-19 2018-04-19 5 4 10.12890/2018_000878 Aneurysm of the Left Portal Branch <p>We describe the incidental finding of an aneurysm of the left branch of the portal vein in a patient without liver pathology. The diagnosis was confirmed by Doppler ultrasound.</p> <p>&nbsp;</p> Diego Martínez Maria Teresa Belmonte Piotr Kosny Maria Rosario Gómez Diego Hellín ##submission.copyrightStatement## 2018-04-17 2018-04-17 5 4 10.12890/2018_000868 Tuberculous Arthritis of the Ankle <p>Tuberculosis (TB) is an infectious disease caused by the <em>Mycobacterium tuberculosis</em> complex (MTBC). Pulmonary TB is the most common form of presentation, but extrapulmonary tuberculosis (EPTB) contributes significantly to morbidity and mortality. Rarely, patients with EPTB develop a form of ankle or foot arthritis. The diagnosis of TB arthritis is often overlooked because of the insidious onset and the non-specific clinical symptoms. Prognosis is generally poor; early diagnosis and delivery of the most appropriate treatment is critical to avoid functional disability.</p> Maria Margherita Rando Giuseppe De Matteis Marco Gessi Matteo Bartoli Marco Galli Giovanni Gambassi ##submission.copyrightStatement## 2018-04-13 2018-04-13 5 4 10.12890/2018_000870 Lung Adenocarcinoma with Gingival Metastasis <p>Gingival metastasis of lung cancer is uncommon. We report the case of an 82-year-old male smoker admitted to the pulmonology department with right pleural effusion. A chest computed tomography (CT) scan showed an invasive right hilar tumour, adherent to the superior vena cava, pulmonary artery, main right bronchus, mediastinal pleura and pericardium with lymphangitic carcinomatosis of the right lung. Pleural biopsy revealed pleural metastasis of pulmonary adenocarcinoma, its primary lung origin being confirmed by immunohistochemistry. One month later, the patient developed an ulcerated polypoid gingival mass. Biopsy of this lesion showed a poorly differentiated carcinoma compatible with metastasis from the lung adenocarcinoma. The patient underwent irradiation of the gingival mass at a dose of 30 Gray, but his condition worsened rapidly and he was not fit for chemotherapy. He received palliative treatment and died 2 months after diagnosis of his metastatic lung cancer.</p> Imen Gargouri Benzarti Wafa Hergli Sana Aissa Samia Kanoun-Belajouza Abdelaziz Hayouni Abdelhamid Garrouche Ahmed Abdelghani Mohamed Benzarti ##submission.copyrightStatement## 2018-04-10 2018-04-10 5 4 10.12890/2018_000861 When a Diuretic Causes Pulmonary Oedema <p><em>Background:</em> Hydrochlorothiazide (HCTZ) is one of the most popular drugs for the treatment of hypertension and heart failure. Most of its side effects are harmless and predictable, but some studies report a few life-threatening reactions to this drug, one of the most dangerous being acute pulmonary oedema. <br> <em>Case Report:</em> A 73-year-old woman was admitted to the Emergency Department with acute respiratory failure due to pulmonary oedema. Her past medical history included long-lasting hypertension with permanent atrial fibrillation and mitral stenosis. Her blood pressure control had been suboptimal, so her cardiologist had changed amlodipine to combination therapy with ramipril and HCTZ. However, 20 min after taking the new drug, the patient experienced fever, vomiting and diarrhoea immediately followed by acute onset of dyspnoea. <br> <em>Conclusion:</em> Since HCTZ is one of the most popular drugs for hypertension treatment and millions of patients take it every day, it is important to keep in mind both the common adverse reactions as well as the dangerous, although rare, ones.</p> Matteo Traversa Andrea Collini Paola Villois Fabrizio Elia Andrea Verhovez Franco Aprà ##submission.copyrightStatement## 2018-04-05 2018-04-05 5 4 10.12890/2018_000864 Chylous Ascites due to Mantle Cell Lymphoma <p>Chylous ascites is rare and results in accumulation of lymph in the abdominal cavity, due to several mechanisms. The ascitic liquid is milky because of the high concentration of triglycerides (&gt;200 mg/dl). The higher incidence compared to the past is explained by increased survival of patients with cancer and more aggressive surgery. We describe the case of an 87-year-old man admitted to the geriatric ward due to general oedema, chylous ascites and loss of weight, explained by mantle cell lymphoma.</p> Ricardo Jorge Gonçalves Fernandes Márcia Leite Joana Cochicho Rafaela Veríssimo Agripino Oliveira ##submission.copyrightStatement## 2018-04-03 2018-04-03 5 4 10.12890/2018_000871 Catatonia and Psychosis as Manifestations of Primary Sjögren’s Syndrome <p>Primary Sjögren’s syndrome (SS) is a chronic, systemic autoimmune disease, most commonly presenting with sicca symptoms—xerostomia and xerophthalmia. Up to one-half of affected individuals also develop extra-glandular involvement. Early diagnosis is important to prevent further complications. This paper describes an atypical case of SS in a 21-year-old woman who presented first with neuropsychiatric symptoms and fever. She was diagnosed and treated for a presumed psychotic episode. However, because she remained febrile, a thorough investigation resulted in the challenging diagnosis of SS.</p> Steeve Neves Rosado Vera Silveira Ana Isabel Reis André Gordinho Carla Noronha ##submission.copyrightStatement## 2018-03-29 2018-03-29 5 4 10.12890/2018_000855 Posterior Reversible Encephalopathy Syndrome (PRES) in Rheumatic Autoimmune Disease <p>Posterior reversible encephalopathy syndrome (PRES) is a clinical-radiological entity with many causes. The primary abnormality is cerebral vasogenic oedema. Here we describe the management of five patients with PRES syndrome who presented to our hospital.</p> Izzat Khanjar Ibrahim Abdulmomen Yousef Yahia Abdul-Wahab Al-Allaf ##submission.copyrightStatement## 2018-03-27 2018-03-27 5 4 10.12890/2018_000866 The ‘SILENT Alarm’: When History Taking Reveals a Potentially Fatal Toxicity <p><em>Introduction:</em> The combination of acute/sub-acute neurological and metabolic derangements should always raise the suspicion of toxicity, either endogenous or exogenous. The adverse effects of psychiatric medications are especially difficult to determine since the psychiatric background of patients is often inaccessible. <br> <br><em>Clinical Presentation:</em> A 66-year-old man presented to the emergency department with dysarthria and uncontrolled tremor, rapidly deteriorating into a complex of severe neurological and metabolic derangements. Only after repeated attempts to take a thorough history was lithium toxicity identified. <br> <br><em>Conclusion:</em> Thorough, comprehensive history taking, including chronic medications and their substitutes, is essential and lifesaving when potentially lethal medications are involved.</p> Sapir Anani Gal Goldhaber Yishay Wasserstrum Amir Dagan Gad Segal ##submission.copyrightStatement## 2018-03-22 2018-03-22 5 4 10.12890/2018_000843